This is the fourth in a new series of posts on military violence against hospitals and medical personnel in conflict zones. It follows from my analysis of air strikes on base hospitals on the coast of France in 1918 here, and of the US air strike on the MSF Trauma Centre in Kunduz, Afghanistan in 2015 here and here. This post, together with the next in the series, is about Syria. They all derive from a new presentation – still in active development – called ‘The Death of the Clinic: surgical strikes and spaces of exception’ that will eventually become an essay in my next book, so I would appreciate any comments or suggestions.

The eye of the storm

Syria’s civil war has multiple origins, but one of the most incendiary incidents took place on 16 February 2011 in the city of Dara’a 80 km south of Damascus near the Jordanian border. Inspired by the spread of the Arab uprisings east across the Maghreb from Tunisia, and the threat they posed to a succession of autocratic regimes, a group of local teenagers decided to daub slogans on the wall of their high school. One of them, a brave 15-year old (who now lives with his family in Jordan), painted this:

‘Ejak el door ya Doctor’ – ‘Your turn, doctor’.

The doctor in question was Bashar al-Assad, Syria’s president, who had trained as an opthalmologist in Damacus and London. In the months to come, Assad would give that slogan a viciously ironic twist.

The immediate response of the security forces to the graffiti was swift and draconian; the boys were rounded up, imprisoned and tortured (see here, here and here). When their relatives protested to the officer in charge he told them:

‘Forget your children. Just make more children. And if you don’t know how to make more, I’ll send someone to show you.’

Local people took to the streets, and as the demonstrations spread on 22 March security forces entered the National Hospital in Dara’a, cleared it of all non-essential medical staff and stationed snipers on the roof who were under orders to fire on protesters. The hospital remained until military control until May 2013; admissions were restricted and snipers continued to fire on the sick and wounded who tried to approach the hospital. On 8 April security forces opened fire on thousands of demonstrators approaching a roadblock; ambulances were prevented from reaching the wounded, and a doctor, a nurse and an ambulance driver were killed when they tried to get through (UN Human Rights Council: ‘Assault on Medical Care in Syria’, 13 September 2013: download here; see also the Human Rights Watch report, ”We’ve never seen such horror’ here).

Others took up the cry, taking to the streets and chanting ‘Dara’a is Syria‘. In many other areas the government stationed snipers, armoured personnel carriers, tanks and heavy artillery at hospitals; doctors suspected of treating protesters were arrested and tortured; security forces forcibly removed patients from hospitals, ‘claiming bullet or shrapnel wounds as evidence of participation in opposition activities’; and ambulances transporting casualties were attacked and pharmacies looted.

The UN Human Rights Council concluded:

This was, sadly, hardly novel. In 2006, at the height of sectarian violence in occupied Baghdad, for example, Muqtada al-Sadr‘s Shi’a militia controlled the Health Ministry and manipulated the delivery of healthcare in order to marginalise and even exclude the Sunni population. As Amit Paleyreported:

‘In a city with few real refuges from sectarian violence – not government offices, not military bases, not even mosques – one place always emerged as a safe haven: hospitals…

‘In Baghdad these days, not even the hospitals are safe. In growing numbers, sick and wounded Sunnis have been abducted from public hospitals operated by Iraq’s Shiite-run Health Ministry and later killed, according to patients, families of victims, doctors and government officials.

‘As a result, more and more Iraqis are avoiding hospitals, making it even harder to preserve life in a city where death is seemingly everywhere. Gunshot victims are now being treated by nurses in makeshift emergency rooms set up in homes. Women giving birth are smuggled out of Baghdad and into clinics in safer provinces.’

He described hospitals as ‘Iraq’s new killing fields’, but in Syria the weaponisation of health care has been radicalised and explicitly authorized by the state.

Counterterrorism and the criminalisation of health care

Doctors were systematically targeted for treating anyone who opposed the government. In April 2012 one surgeon from Idlib toldAnnie Sparrow:

‘We were detained in the hospital for several days. Tanks parked out front, artillery in the wards, snipers on the roofs shooting patients who tried to come. They took our names, and summoned three of the five security branches – state, political and military. I was interrogated and forced to sign several commitments not to treat anyone not pro-regime. Of course, as soon as I was released I violated it immediately…the city was full of wounded and sick people. Soon after that a friend who worked in military security let me know I was now “wanted” [for my work], the charge being that I was the leader of a terrorist group. So I went into hiding, and moved my family to Turkey. In retaliation my brother was executed.’

The State of Emergency that had been in force in Syria since 1962 was abruptly ended on 21 April 2012. But on 2 July a new Counter-terrorism Law came into force that criminalised all medical aid to the opposition. Here is Annie Sparrow again:

As Neil Macfarquhar and Hala Droubireported for the New York Times in March 2013, doctors repeatedly found themselves in the cross-hairs. Here, for example, is the case of Dr Mohamad Nour Maktabi:

The Counter-terrorism Law also declared that all medical facilities operating in opposition-held areas without government permission were illegal – and thereby transformed them (under Syrian law, at least) into legitimate targets of military violence.

Air wars and ‘surgical strikes’

The nature of military and paramilitary violence has changed during the course of the war; shooting and mortar-fire have increasingly been supplemented by air strikes.

Even in the early stages of the war doctors were confronting what one trauma specialist called ‘unimaginable injuries’. Dr Rami Kalazi, a neurosurgeon in east Aleppo, explained:

‘In the beginning, we saw new injuries that we did not know how to treat. Fortunately, at the beginning of the revolution and when we began working in field hospitals, there was more freedom of movement. In 2012 and 2013, there was no such thing as “barrel bombs” and there was no violent shelling from airplanes, so many visiting foreign doctors came…

‘But even so, they told us that they were seeing injuries that they had never seen before in books or textbooks or in the hospitals where they worked in their home countries. Unfortunately, reality forces you to learn.’

But air strikes transformed the calculus of injury. Many more casualties resulted from each attack, and the wounds of those who survived were often far more serious.

The US-led coalition has carried out multiple airstrikes primarily in areas controlled by IS, and the campaign has caused (minimally) hundreds and probably several thousand civilian casualties – see my analysis of specific US air strikes here and here, for example – but the Syrian Arab Air Force has concentrated its fire on areas controlled by other rebel groups (see Jeffrey White‘s analysis here).

A favourite tactic has been the deployment of ‘barrel bombs‘ – in effect, aerial IEDs: oil drums filled with high explosive and cut rebar to act as shrapnel – dropped from helicopters (see Human Rights Watch here). Basel al-Junaididescribed witnessing their impact:

I saw the aftermath of a barrel bomb. I saw human remains scattered in the street; I heard the screaming. I’m trained as a doctor, but I was unable to act. I just stood there, petrified. The West thinks we’re used to this, but we aren’t of course. We’re like anyone else – we use computers and cars, not camels and tents…

Another doctor who worked in Syria said he kept ‘a drawing from a second grader in Aleppo, showing helicopters bombing the city, blood and destruction below.’ Chillingly, ‘the dead children are smiling while the living ones are crying.’

From September 2015) the Russian Air Force, often acting in concert with the Syrian Arab Air Force, has also concentrated on targets in areas controlled by other opposition groups:

Russia has routinely denied these charges, but from 30 September to 12 October 2015 its Ministry of Defence published videos of 43 airstrikes. Bellingcat, aided by crowdsourcing, identified the exact location of 36 of them and overlaid them on the ministry’s own map identifying which groups controlled what parts of the country (see the full report, ‘Distract, Deceive, Destroy’, here):

‘The result revealed inaccuracy on a grand scale: Russian officials described 30 of these videos as airstrikes on Isis positions but in only one example was the area struck in fact under the control of Isis, even according to the Russian MoD’s own map.’

The effect of these air strikes has been devastating on the population at large. To make matters even worse, air strikes cannot target individual doctors and have instead frequently been directed against hospitals and other medical facilities. This compromises not only trauma care for the wounded but also the treatment of chronic and infectious diseases:

Doctors and other medical staff had to adjust to a new, sickening vulnerability. Here is one OB/GYN who was still working in a hospital in East Aleppo when she was interviewed on Public Radio International in August 2016:

Carol Hills, PRI: Doctor Farida, did I just hear a noise there? Was that some sort of attack that I just heard?Dr Farida Almouslem: It’s attack. [Laughs]. It’s normal. It’s away from me. Not next to me. These noises are all the time.Hills: Do you and the doctors and patients you work with feel safe inside the place where you’re working?Dr Farida: No. It’s not safe. I work at the third floor in my hospital. And many times the wall was perforated. So every woman came to the hospital, she knows that there is a danger on her life. So they just give the delivery, or give the birth, and then go home. She escapes to home because she knows our hospital is always targeted.

Other doctors in opposition-held areas said the same. Here is Dr Mohamed Tennari, director of an above-the-ground field hospital in Idlib:

‘When I am in the hospital, I feel like I am sitting on a bomb. It is only a matter of time until it explodes. It is wrong − a hospital should not be the most dangerous place. I wish I could say that targeting a hospital in Syria is unique, but is not.’

In the face of these escalating attacks, hospitals in opposition-held areas have tried to conceal their locations from the Syrian government. In contrast to the protocol adopted by the MSF Trauma Centre in Kunduz, they have been markedly reluctant to provide their GPS coordinates (and see MSF’s explicit comparison between what happened in Kunduz and the situation in Syria here):

But this has trapped them in a grim Catch-22. Michiel Hofman of Médecins sans Frontières – which is not permitted to operate in government-controlled areas in Syria – explains:

‘Hospitals that MSF supports in Syria are bereft of the possible protection of being clearly marked as a hospital or sharing of GPS coordinates, as the Syrian government passed an anti-terrorist law in 2012 that made illegal the provision of humanitarian assistance – including medical care – to the opposition, forcing most health structures to go underground and operate without governmental medical registration. The bombing parties can then conveniently claim they were unaware it was a hospital they hit.’

More often, the Syrian government and its allies routinely describe the bombed building as a ‘so-called hospital’. After an air strike on an MSF-supported hospital near Maarat al-Numan in Idlib on 15 February 2016 Bashar Jaafari, Syria’s ambassador to the United Nations, made this statement:

‘The so-called hospital was installed without any prior consultation with the Syrian government by the so-called French network called MSF which is a branch of the French intelligence operating in Syria… They assume the full consequences of the act because they did not consult with the Syrian government. They did not operate with the Syrian government permission.’

The allies of the Syria government are not confined to Russia and Iran. On 27 April 2016 the Al Quds hospital in Aleppo was hit by two air strikes that killed 55 people – among them two specialists, including Dr Muhammad Waseem Maaz, Al Quds’s pediatrician – and severely damaged the hospital. When it partially reopened 20 days later its capacity was reduced from 34 to 12 beds. MSF conducted a detailed review of the operations of the hospital and the circumstances of the attack:

Here is Professor Tim Anderson on what he calls ‘The “Aleppo Hospital” Smokescreen‘ (and for reasons that will become obvious I am so tempted to put scare-quotes around the title that adorns his post; the Department of Political Economy at the University of Sydney lists him as a Senior Lecturer not a Professor, but perhaps anxiety over the appellation ‘Doctor’ is contagious):

‘…the story of Russian or Syrian air attacks on the ‘al Quds hospital’ gained prominence in the western media… CCTV showed people leaving this ‘hospital’ before an explosion.

‘The building is in the southern al-Sukkari district, which has been a stronghold of Jabhat al Nusra for some years. Many Aleppans had never heard of ‘al Quds hospital’. Dr Antaki [Aleppo Medical Association in Western Aleppo] says: “This hospital did not exist before the war. It must have been installed in a building after the war began”…. This facility was not a state-run or registered facility.’

Anderson is joined in his disinformation effort by Eva Bartlettwriting in the ‘OffGuardian’:

‘Dr. Zahar Buttal, Chairman of the Aleppo Medical Association … said: “The media says the only pediatrician in Aleppo was killed in a hospital called Quds. In reality, it was a field hospital, not registered.”

As for the pediatrician, “We checked the name of the doctor and didn’t find him registered in Aleppo Medical Association records.”…

… central to the lies were the bias and propaganda of the very partial, corporate-financed Médecins Sans Frontières (MSF), which supports areas in Syria controlled by terrorists, specifically Jabhat al-Nusra…’

To repeat: the Syrian government has refused to register or recognise any hospitals operating in areas outside its control – hence the snide reference to ‘so-called hospitals’ and Anderson’s meretricious scare-quotes – and it does not permit MSF to operate in areas under its control (despite repeated requests). As for the disappearance of Dr Muhammad Waseem Maaz from the Syrian government’s registry (though I have no doubt he was on other lists maintained by the regime) the director of the Children’s Hospital in Aleppo provides a graceful tribute to him here. And here is the doctor whose death these commentators dismiss so lightly (if you have the stomach for it, you can see his last moments caught on CCTV here):

What, apart from the grotesque stipulations of the Syrian state, makes them think it proper to withdraw medical care from those living – surviving – in rebel-held areas? International humanitarian law is unequivocal: they are entitled to medical treatment and to be protected whilst it is provided to them.

In rebel-held areas medical care has increasingly moved outside what were once established hospitals into the clandestine ‘field hospitals’ referred to above, which have been given numbered code-names to conceal their locations. Some, like those established by MSF, follow strict medical protocols and, according to a study of one operating in Jabal al-Akrad by Miguel Trelles and his colleagues, they have (for a time) been able to provide high-quality medical care with remarkable survival rates (‘Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria’, Conflict and Health (December 2015)). As the attacks on them have increased and qualified personnel and medical supplies have become scarce, however, many have become exercises in improvisation:

Some of these hospitals have literally gone underground. ‘‘In our worst dreams – in our worst nightmares – we never thought we would have to fortify hospitals,’ declared DrZaidoun al-Zoabiof the Union of Medical Care and Relief Organizations. ‘It’s not humane. It’s impossible to comprehend.’

Subterranean locations have been used not only to protect the hospitals but also to protect local populations. Charles Davisreported that

‘whether it’s a vehicle or a building, anything that’s identifiable as providing medical care is ripe for an airstrike, so that staff have now taken to covering up any distinguishing characteristics. Even so, [Dr Abdulaziz Adel, a surgeon in East Aleppo, admits that] local residents are “always begging us to go away, take your hospital away from us or otherwise we’ll be a target.”‘

When the Syrian-American Medical Society proposed to build a hospital in Hama in 2014, local people begged them to locate it outside the city and so SAMS excavated what became the Dr Hasan al Araj Hospital, better known as ‘The Cave’:

Supply chains and kill-chains

As the civil war ground on, even the most basic medical supplies became scarce and obtaining them ever more dangerous. In March 2015 MSF reported that:

‘Even if it is available, many suppliers do not want to risk selling material like gauze or surgical threads when they know it is going to be sent into North Homs. Gauze is considered synonymous with war surgery, and often a supplier is not willing to take the risk of being arrested or shut down for supplying a besieged area.’

‘It is precious, dangerous, incriminating. There are secret outlets supplying us with gauze.’

At the end of last year the Guardianprovided this image of one of the secret factories:

In East Aleppo, hospitals have been forced to use tunnels to bring in medical supplies (more from Ellen Francis and her colleagues here):

The risks are formidable and the costs have been almost prohibitive. Ellen Francis and her colleagues at Columbia’s Graduate School of Journalism report that in January 2014 the Free Syrian Army and the Syrian Arab Army agreed an uneasy and ragged cease-fire in Barzeh, a small town on the northern edge of Damascus. There a team from the Union of Free Syrian Doctors was able to buy medical supplies from merchants who travelled out from the capital.

The merchants paid a 20 per cent ‘customs fee’ to Syrian Army soldiers; the agents for the doctors then paid a ‘tax’ to get the supplies through the Harasta checkpoint on the Army-controlled highway, and then a ‘toll’ to the rebels (‘tunnel lords’) who controlled the tunnels into Ghouta.

The combined fees inflated the price of medical supplies. A litre of serum used to help the body replenish lost blood cost $1 in government-controlled areas and $3.50 to $10 via the tunnel route. Ghouta was using about 10,000 litres of serum per month. The supply chain was subsequently severed once Barzeh itself came under siege and was cut off from Damascus.

Some humanitarian aid has crossed the lines by more conventional routes – conventional for a war zone at any rate – but medical supplies have routinely been removed from aid convoys. On 19 May 2016 the UN Secretary-General reported to the Security Council:

‘[By May] 2016, WHO [had] submitted 21 individual requests to the Government of the Syrian Arab Republic to deliver medical supplies to 82 locations in 10 governorates. The Government approved five requests [while] 16 requests remained unanswered.

‘The removal of life-saving medicines and medical supplies continued, with nearly 47,459 treatments removed from convoys in April intended for locations in Homs, Aleppo and Rif Dimashq governorates. Removed items included surgical supplies, emergency kits, trauma kits, mental health medicines, burn kits and multivitamins. Removals extended to basic items, such as antibacterial soap, which was removed from midwifery kits. Items were also removed from other kits, notably surgical tools…’

Even then, aid convoys are not safe. Four months later to the day a UNICEF aid convoy delivering supplies to a Syrian Red Crescent warehouse at Urum al-Kubra in Aleppo was attacked from the air, killing at least 18 people and destroying 18 of the 31 trucks. Most analysts have concluded that the Russian Air Force was responsible, perhaps acting in concert with the Syrian Arab Air Force – see for example here and here– but the Russian Ministry of Defence and the usual suspects have variously blamed spontaneous combustion, a ground attack by rebels and a US drone attack.

These shortages are threaded into dispersed and precarious siege economies that gravely affect the health of local populations. In December 2015 an estimated 400,000 people were surviving without access to life-saving aid in 15 besieged locations across Syria; the figures gathered by Siege Watch are even higher.

Surrounded by 6,000 land-mines and 65 sniper-controlled checkpoints, Madaya’s 40,000 inhabitants have been under siege since July 2015; 32 people died of starvation and malnutrition in December 2015 alone. One resident interviewed by Amnesty International in January 2016 described the catastrophic situation:

‘Every day I wake up and start searching for food. I lost a lot of weight, I look like a skeleton covered only in skin. Every day, I feel that I will faint and not wake up again… I have a wife and three children. We eat once every two days to make sure that whatever we buy doesn’t run out. On other days, we have water and salt and sometimes the leaves from trees. Sometimes organizations distribute food they have bought from suppliers, but they cannot cover the needs of all the people.

‘In Madaya, you see walking skeletons. The children are always crying. We have many people with chronic diseases. Some told me that they go every day to the checkpoints, asking to leave, but the government won’t allow them out. We have only one field hospital, just one room, but they don’t have any medical equipment or supplies.’

An aid convoy was allowed in four days after this interview.

There are also grave shortages of skilled medical personnel. The doctors who remain in opposition-held areas have all had to learn new skills sometimes far beyond their original training. In March 2015 one young surgeon working in an MSF-supported hospital east of Damascus recalled:

‘There was a pregnant woman who was trapped during the time we were under full siege. She was due to deliver soon. All negotiation attempts to get her out failed. She needed a cesarean operation, but there was no maternity hospital we could get her to, and I had never done this operation before.

A few days before the expected delivery date, I was trying to get a working internet connection to read up information on doing a C-section. The clock was ticking and my fear and stress started to peak. I wished I could stop time, but the woman’s labour started…’

In 2015 OCHA estimated that more than 40 per cent of pregnant women in these areas now scheduled C-sections to reduce the risk of an attack preventing them from obtaining care.

In some cases doctors can call on skilled overseas help via Skype from consultants on call 24/7 in the United States, Canada and the United Kingdom. Ben Taub has written movingly of the extraordinary efforts of what he calls ‘the shadow doctors’ enlisted in ‘the underground race to spread medical knowledge as the Syrian regime erases it.’ One of the most active is Britain’s Dr David Nott:

But not all those seeking specialist help are qualified surgeons. In the field hospital serving the besieged town of Madaya medical care has been provided by a dentist, a dental student and a veterinarian. Avi Asher-Schapiroreports:

‘The five-year civil war has plunged the Madaya clinicians into the deep end, forcing them to perform medical procedures that push them far beyond their training. They have treated countless gunshot victims, performed seven amputations, over a dozen C-sections, and diagnosed everything from meningitis to cancer.’

As he explains, this remarkable trio has also relied on remote medicine:

These are all extraordinary responses to near-impossible, life-threatening situations. But their successes have been short-lived.

The Madaya clinic was forced to close in November 2016:

And the M10 hospital where Nott helped direct surgery – the largest trauma and ICU centre in East Aleppo – was hit by successive, catastrophic air strikes. First, an attack on 28 September 2016 left only half the hospital operational. On 1 October Xisco Villalonga, MSF’s Director of Operations, reported that

‘Bombs are raining from Syria-led coalition planes and the whole of east Aleppo has become a giant kill box.’

That night multiple strikes on M10 killed two people and injured ten others; the hospital had to be evacuated because one crater was so deep there were fears that the rest of the building would collapse.

But the ordeal was not over: there were further, devastating strikes on 3 October:

The underground hospitals have fared no better. ‘The Cave’ – 15 metres inside a mountain, remember – was hit by two ‘bunker-buster’ bombs at 1500 on 2 October 2016. After 35 staff and patients had been evacuated a second strike occurred in the early evening involving missiles and cluster bombs. The E.R. was wrecked, ceilings collapsed, cement walls crumbled and generators, water tanks and medical equipment were destroyed (see image below). Nobody was seriously injured but the hospital sustained critical damage and has been closed indefinitely. It used to treat 300 patients and perform 150 surgeries a month.

The exception to the exception

Once safe places under the protection of international humanitarian law – the exception to the space of exception that is the conflict zone – hospitals have become the targets of a new and extraordinarily vicious modality of modern war. The systematic attacks on hospitals have not only threatened the lives of patients and healthcare workers; they have also made many patients reluctant to seek medical treatment at all. In February 2015 a report from the Centre for Public Health and Human Rights at Johns Hopkins University was already warning of the consequences:

‘Unless they feel their life is in danger, many people won’t go to hospital because it is targeted for bombardment’ [Physician, Aleppo]. Two physicians reported that fear of travel and an understanding that the hospital is a target has led to a 50% decrease in clinic visits and surgery cases, even though the level of violence has not decreased.

Dr Farida, the OB/GYN in East Aleppo interviewed earlier, no longer has a hospital to work in – the last remaining hospital was reduced to rubble and closed on 18 November – and she now provides what medical care she can from a basement:

‘People know it’s a basement, but they are afraid to come here because they know any health facility is deliberately targeted by the regime. For women, they are afraid to come — but they don’t have any other option. When they don’t have a car or fuel to come here, they have to give birth at home. Women are bleeding at home and babies are born dehydrated without oxygen.’

Those that do make the precarious journey to a field hospital or other medical facility almost always now find that their care is compromised by the shortage or even the absence of doctors, nurses, medical supplies and even the most basic medical equipment. So doctors use ordinary sewing cotton instead of surgical thread; local anaesthetic where they would normally use a general, or even home-made, improvised variants. Dr Zaher Sahloul, who still tries to provide help to colleagues in Syria from his home in Chicago via WhatsApp, explains:

‘We operate on the mindset that they have basic things we take for granted… The reality is, they don’t have 90 percent of the things we think they have. They know better what they have and what they can do with it. These people are facing decisions we will never face in our lives. If you have 10 patients dying, who will you see first? Do you use spoiled gauze and dirty tubes at the risk of infection? It’s Hell for them.’

As I write, the Syrian Arab Army and its supporting militias are advancing into East Aleppo, where air strikes and artillery bombardments have left more than 250,000 people without access to any form of advanced medical care. The World Health Organisation announced that ‘although some health services are still available through small clinics, residents no longer have access to trauma care, major surgeries, and other consultations for serious health conditions.’

The final irony – although in this catalogue of horrors it probably isn’t the last at all – is that the Kremlin has announced that it will send two mobile hospitals to treat patients from East Aleppo. The Defence Ministry will operate ‘a special 100-bed clinic with trauma equipment for treating children’ and the Emergencies Ministry will provide a 50-bed clinic capable of treating 200 outpatients a day.

While the Kremlin congratulates itself on its ‘humanity’, we need to remember that this minimalist contribution would not have been necessary at all had medical neutrality been respected and doctors and nurses, hospitals and clinics not been so ruthlessly, systematically and deliberately targeted in the first place.

UPDATE: On 5 December the Defence Ministry’s mobile hospital (set up in West Aleppo to treat patients from East Aleppo) came under mortar fire from the crumbling opposition-held area to the east; one Russian doctor and two paramedics were killed. It’s not clear whether the hospital was deliberately targeted – there have been accusations that the co-ordinates of the hospital must have been given to the militants for it to have been hit ‘right at the moment when it started working‘ – or whether it was caught in the indiscriminate shelling and mortar-fire that has hit other hospitals in West Aleppo.

But I should make two things clear. First, attacks on hospitals in West Aleppo – even though I don’t think they have exhibited anything like the scale or the systematicity of those directed against medical facilities and healthcare workers in opposition-held areas – are as reprehensible as those on hospitals in the East. Second, the muted response from the US-led coalition to the shelling of the Russian field hospital is deeply disturbing. The International Committee of the Red Cross announced after the attack that ‘all sides to the conflict in Syria are failing in their duties to respect and protect healthcare workers, patients, and hospitals, and to distinguish between them and military objectives.’ The Russian Ministry of Defence dismissed this as a ‘cynical’ display of indifference to the deaths of its doctors, but I don’t read it like that at all – what is cynical is the partisan appeal to medical neutrality when it suits, and its systematic violation when it doesn’t.

This is the third in a new series of posts on military violence against hospitals and medical personnel in conflict zones. It examines some of the key issues arising from the US attack on the Trauma Centre run by Médecins Sans Frontières (MSF) in Kunduz on 3 October 2015; it follows directly from my detailed analysis of the attack here and prepares the ground for a still more detailed analysis of attacks on hospitals, doctors and casualties in Syria to follow.

There are at least four main issues arising from the US attack on the MSF Trauma Centre in Kunduz that spiral out into a wider argument about what I will later call ‘The Death of the Clinic’. I’m treating ‘the clinic’ here as a topological figure that extends from the body of the wounded through the evacuation chain to the hospital itself. The clinic has been accorded a privileged status within the space of exception that is the modern conflict zone – a complicated, fractured space in which killing is made permissible subject to the protocols of international humanitarian law – so that the clinic becomes an exception to the exception and its inhabitants granted a conditional immunity from attack.

It’s important to understand that this legal armature is not immutable, and that changes (and challenges) to it arise through both (geo)political and military actions; international humanitarian law is not a deus ex machina, somehow above the fray, but is thoroughly entangled with the prosecution of military violence. More on this to come, but for now it will be enough to list some of the major protections accorded to the clinic in war-time.

Ambulances and military hospitals shall be acknowledged to be neuter, and, as such, shall be protected and respected by belligerents so long as any sick or wounded may be therein. Such neutrality shall cease if the ambulances or hospitals should be held by a military force … A distinctive and uniform flag shall be adopted for hospitals, ambulances and evacuations.

Under the Hague Regulations (1899/1907) that were in force during the hospital raids in France at the end of the First World War:

… all necessary steps must be taken to spare, as far as possible, … hospitals, and places where the sick and wounded are collected, provided they are not being used at the time for military purposes. It is the duty of the besieged to indicate the presence of such buildings or places by distinctive and visible signs, which shall be notified to the enemy beforehand.

Under the Geneva Conventions (1949) – whose provisions applied to the attack on the MSF Trauma Centre a hundred years later – there is a similar immunity granted to the military-medical machine:

The protection to which fixed establishments and mobile medical units of the Medical Service are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after a due warning has been given, naming, in all appropriate cases, a reasonable time limit and after such warning has remained unheeded.

And this is explicitly extended beyond the military-medical machine to institutions like the MSF Trauma Centre:

Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack but shall at all times be respected and protected by the Parties to the conflict.

The protection to which civilian hospitals are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after due warning has been given, naming, in all appropriate cases, a reasonable time limit and after such warning has remained unheeded.

In so doing the treatment of hostile combatants is also explicitly provided for and protected:

The fact that sick or wounded members of the armed forces are nursed in these hospitals, or the presence of small arms and ammunition taken from such combatants and not yet been handed to the proper service, shall not be considered to be acts harmful to the enemy.

The language and specifications change, but there is nevertheless a consistent thread running through these provisions. It has been stretched – and perhaps broken – by the attack on the MSF Trauma Centre, and here I’ll focus on four issues that have proved contentious. First, the visual identification of the Trauma Centre; second, the alleged breach of its conditional immunity; third, the construal of the attack as a war crime; and fourth, the putative rejection of medical neutrality altogether.

(1) Visual identification

International humanitarian law (IHL) requires those responsible for hospitals ‘to indicate their presence’ – the language varies – in order to ensure their protection, and here the US military investigation made this finding (all page numbers in brackets refer to the redacted report):

The center roof of the MSF Trauma Center was marked with two rectangular MSF flags… The front and sides of the MSF hospital were marked from the street view and a MSF flag flew in the courtyard. The MSF Trauma Center was not marked with any internationally recognized symbols such as a red cross, red crescent or a red “H”. If it had been marked with these symbols, it is possible the Trauma Center would not have been engaged. (082)

This counterfactual does not loom large in the report or its recommendations, but Charles Dunlap (at Lawfire) has seized upon it to berate MSF:

Put another way, isn’t it foreseeable that in an exceptionally chaotic combat situation (where a belligerent is making use of civilian buildings to conduct combat operations) that mistakes could occur in identifying a protected structure absent Protocol III markings or at least something to make it identifiable at a distance, especially when it’s known that attacking aircraft are being used? Wouldn’t reasonably prudent persons have marked their medical facility with an internationally-recognized symbol or something of similar clarity to the warring parties? Wouldn’t due care demand it in that situation?

In accusing MSF of ‘imprudence’ and even recklessness Dunlap applies a double standard. He repeatedly insists that the US and the Afghan militaries confronted ‘an extraordinarily intense situation’ in Kunduz, that they faced ‘terrible urgency’ and ‘enormous pressure’ as they operated ‘in the turmoil of a war zone’ – all of which is undoubtedly true – but he uses this to excuse their mistakes while refusing to extend the same privilege to MSF.

Let me remind you of Dr Kathleen Thomas‘s account of working in the ER (above) once the city had fallen to the Taliban:

The first day was chaos – more than 130 patients poured through our doors in only a few hours. Despite the heroic efforts of all the staff, we were completely overwhelmed. Most patients were civilians, but some were wounded combatants from both sides of the conflict. When I reflect on that day now, what I remember is the smell of blood that permeated through the emergency room, the touch of desperate people pulling at my clothes to get my attention begging me to help their injured loved ones, the wailing, despair and anguish of parents of yet another child lethally injured by a stray bullet whom we could not save, my own sense of panic as another and another and another patient was carried in and laid on the floor of the already packed emergency department, and all the while in the background the tut-tut-tut-tut of machine guns and the occasional large boom from explosions that sounded way too close for comfort.

In any case, MSF had clearly ‘indicated their presence’ to both the US and Afghan authorities by providing them with the GPS co-ordinates of the Trauma Centre (see my previous discussion here). Dunlap finds this ‘commendable’ but ‘legally problematic’.

Instead, he is fixated on the absence of a Red Cross flag from the roof, in which case he might reflect on another passage from the report. On 2 October, the day before the air strike, MSF phoned the Special Operations Task Force in Bagram to develop a contingency plan: while the Taliban were respecting the neutrality of the Trauma Centre and ‘treating the government casualties well’, they wanted to know the feasibility of extracting their patients should conditions deteriorate. During that conversation they were advised to ‘take the signs normally affixed to the sides of the trucks and to install them on the top of the vehicles for easy identification by aircraft during this or any future MSF resupply operations‘ (503; my emphasis). This surely makes it clear that the US military anticipated no difficulty in recognising MSF’s flag and logo as symbols of medical neutrality.

(2) Conditional immunity

IHL makes it clear that treating wounded combatants does not compromise the protections afforded to a medical facility; that occurs only if it is used as a base from which ‘to commit, outside their humanitarian duties, acts harmful to [one of the belligerents]’. I’ll address the intervening clause – ‘outside their humanitarian duties’ – under (4) and confine my discussion here to the alleged militarisation of the clinic.

MSF’s internal review found that its unambiguous ‘no weapons‘ policy was adhered to:

All of the MSF staff reported that the no weapons policy was respected in the Trauma Centre. [Since the KTC opened, there were some rare exceptions when a patient was brought to the hospital in a critical condition and the gate was opened to allow the patient to be delivered to the emergency room without those transporting the patient being first searched. In each of these instances, the breach of the no weapon policy was rapidly rectified.] In the week prior to the airstrikes, the ban of weapons inside the MSF hospital in Kunduz was strictly implemented and controlled at all times and all MSF staff positively reported in their debriefing on the Taliban and Afghan army compliance with the no-weapon policy.

The US military investigation accepted this was indeed the case:

Evidence provided to the investigation team supports the MSF internal initial report’s characterization that their no-weapons policy was adhered to with rare exceptions (038, note 15).

Mathieu Aikins‘s interviewees also confirmed the absence of weapons from the Trauma Centre:

Though the MSF hospital was crowded with fighters, whether patients or caretakers (each patient was allowed one), staff members and civilians who were present said the insurgents respected the rules. They left their weapons outside or handed them over at the gun lockers at the entrance. One employee recalled seeing a fighter give up his weapon but forget his ammunition vest; when the employee nervously approached the fighter about it, the man apologized profusely and handed it over. “We had respect for the hospital, as they were serving the people,” said Shahid, the Taliban commander. “I myself went there once when one of our men was wounded, and before entering we submitted our weapons outside.”

Aikins goes on to report that patients were allowed to retain their cellphones, and some of their caretakers retained hand-held radios whose transmissions were intercepted by Afghan special forces. They in turn concluded that not only were the Taliban inside the hospital but were using it as a base: ‘They had raised their flag and established their headquarters there.’ On 1 October, presumably in response to these reports, the Pentagon contacted MSF in New York to ask whether ‘they had a large number of Taliban “holed up”’ in the Trauma Centre, and were assured that the only Taliban inside the hospital were wounded patients.

But the suspicions clearly remained, and festered to such a degree that some of those on the ground were convinced that the hospital had been overrun by Taliban fighters. Associated Press reported that the radio intercepts prompted US analysts to request ‘specific intelligence-gathering flights over the hospital’ – their outcome has never been disclosed – and on 1 October a senior Special Forces commander (whether in Kabul or in Kunduz is unclear) wrote in his daily log that the Trauma Centre was under Taliban control and that he planned to clear it in the coming days. At least some of the Green Berets in Kunduz agreed with his assessment: ‘They were using it as a C2 node … They had already removed and ransomed the foreign doctors, and they had fired on partnered personnel from there.’ Indeed, after the attack a senior US officer in Kabul was told – by whom has been redacted – that ‘there were three dead Military-Aged Males near the hospital, identified as Taliban by the local population. They were using the hospital as a command post (using its protected status)’ (275).

But all of this was fantasy, and the investigation discounted it. Although US intelligence reported that insurgents were present at the hospital at the time of the strike, the investigation accepted that this was for medical treatment and they could trace ‘no specific intelligence reports that confirm[ed] insurgents were using the MSF Trauma Center as an operational C2 [command and control] node, weapons cache or base of operations’ (085). In addition, they determined that observations made from the AC-130 revealed neither substantive hostile acts nor demonstrations of hostile intent – only ‘unarmed individuals walking around [or] sitting in chairs’ (085). The report describes these as ‘ordinary and innocuous acts’ (055), but to at least one member of the aircrew that was in itself grounds for suspicion: ‘In his experience, when AC-130 aircraft fly over insurgents, they act normally or try to stay normal… [whereas] civilians will not try to be nonchalant when the aircraft is overhead’ (093, note 304). Damned if you do, and damned if you don’t: when everything is construed as hostile, even the most innocent acts are transformed into somcething sinister.

The claims made by Afghan forces were even wilder. Here is May Jeong in The Intercept:

On the night of the hospital strike, a unit commander with the Ministry of Defense special forces was at the police headquarters taking fire from the direction of the hospital. “Vehicles were coming out of there, engaging, then retreating,” he told me. When I pointed out that he couldn’t have seen the gate of the hospital from where he was, several hundred meters away, he said that he was sure because he had personally interrogated a cleaner who told him that the hospital was full of “armed men using it as a cover.” The cleaner told the commander that there were Pakistani generals using the hospital as a recollection point and that they had set up a war room there. When I challenged his line of vision again, he responded, “Anyone can claim anything. The truth is different.”

[Amrullah] Saleh, [former head of the National Security Directorate and] the author of the 200-page Afghan commission report on the fall of Kunduz … believed that the “hospital sanctity had been violated” and held out as evidence 130 hours of recorded conversations with more than 600 interlocutors. “I spoke with the MSF country director,” Saleh told me recently. “They don’t deny that the hospital was infiltrated by the Taliban.”

But of course they did deny it: repeatedly, emphatically and convincingly.

The US military investigation was unequivocal: it found multiple violations of the military’s own Rules of Engagement and of international humanitarian law.

The first rule of customary international humanitarian law, now codified in the Additional Protocols to the Geneva Conventions, is distinction:

The parties to the conflict must at all times distinguish between civilians and combatants. Attacks may only be directed against combatants. Attacks must not be directed against civilians.

The investigation found that both the Ground Force Commander (GFC) and the aircraft commander failed to exercise this core principle:

Neither commander distinguished between combatants and civilians nor a military objective and protected property. Each commander had a duty to know, and available resources to know that the targeted compound was protected property’ (075-6).

Launching an attack which may be expected to cause incidental loss of civilian life, injury to civilians, damage to civilian objects, or a combination thereof, which would be excessive in relation to the concrete and direct military advantage anticipated, is prohibited.

The investigation found this to have been disregarded too:

The GFC and the aircraft commander failed to exercise the principle of proportionality in relation to the direct military advantage (076).

Both principles are deceptively simple, and in ‘The Passions of Protection: Sovereign Authority and Humanitarian War’ Anne Orford reminds us that IHL ‘immerses its addressees in a world of military calculations.’ In practical terms the distinction between civilians and combatants in today’s conflicts is rarely straightforward, but in this case the No-Strike List plainly recognised the protected status of the Trauma Centre and there is no convincing evidence that its immunity had been compromised. In addition, the balance between loss of civilian life and military advantage is weighed on the military’s own scales – ‘expected’; ‘excessive’; ‘anticipated’: these are not self-evident calculations – but even if the GFC or the aircraft commander had grounds to believe the Taliban were firing from the hospital the Pentagon’s own Law of War Manual (which is not without its own controversies: see here and, specifically on proportionality, here and here) advises under §7.10.3.2 that

The obligation to refrain from use of force against a medical unit acting in violation of its mission and protected status without due warning does not prohibit the exercise of the right of self-defense. There may be cases in which, in the exercise of the right of self-defense, a warning is not “due” or a reasonable time limit is not appropriate. For example, forces receiving heavy fire from a hospital may exercise their right of self-defense and return fire. Such use of force in self-defense against medical units or facilities must be proportionate.

Not only was there was no evidence of hostile let alone ‘heavy fire’ from the Trauma Centre but the AC-130 was also monitoring the progress of the Afghan Special Forces convoy that it was tasked with protecting and knew perfectly well that it was still within the perimeter of the airfield. This was not a time-sensitive target (the report makes that crystal clear) and neither the GFC nor the aircraft commander had reason to believe that any putative threat to Afghan or US forces was so grave and so sustained that it called for an air strike involving multiple passes by the AC-130 – over 30 minutes according to the US military, an hour according to MSF – delivering such intense fires that the building was virtually destroyed.

For these reasons many commentators – and MSF (‘Under the clear presumption that a war crime has been committed, MSF demands that a full and transparent investigation into the event be conducted by an independent international body’) – have insisted that the attack was a war crime.

But others (including the US military) have concluded that it was not. US Central Command’s initial summary – produced before the redacted report was released – accepted that there had been breaches of both the Rules of Engagement and of IHL (‘the law of armed conflict’) but noted that

the investigation did not conclude that these failures amounted to a war crime. The label “war crimes” is typically reserved for intentional acts – intentionally targeting of civilians or intentionally targeting protected objects. The investigation found that the tragic incident resulted from a combination of unintentional human errors, process errors and equipment failures, and that none of the personnel knew that they were striking a medical facility.

The report has been so heavily redacted so that this legal discussion is unavailable (see also the commentary by Sarah Knuckey and two of her students here). We do know that the investigation team included an unnamed legal advisor from US Central Command (CENTCOM) and that its report was subject to legal review by the Staff Judge Advocate, who accepted its findings as ‘legally sufficient’ with several, redacted exceptions – though there is no way of knowing what they were (007-009). We know too that General John Campbell, who ordered the investigation as commander of US Forces in Afghanistan, subsequently disapproved a number of findings and recommendations ‘not related to the proximate cause of the strike’ (002) but, again, the details have been excised.

General Joseph Votel, commander of CENTCOM, repeated the summary statement’s disavowal of war crimes at a Pentagon Press Briefing on 29 April 2016, and in responding to a storm of questions from plainly incredulous reporters (above) he elaborated:

… an unintentional action takes it out of the realm of actually being a deliberate war crime against persons or protected locations…. They were absolutely trying to do the right thing; they were trying to support our Afghan partners; there was no intention on any of their parts to take a short cut, or to violate any rules that were laid out for them. And they were attempting to do the right thing. Unfortunately, they made a wrong judgment in this particular case…

Jens David Ohlin explains the disputation (which Faye Donnelly helpfully re-casts as one between two contending narratives whose speech-acts struggle to realize their performative force):

The problem is that the killing of the innocent civilians was not intentional, it was accidental. As a matter of criminal law, it was either reckless or negligent … but the civilian killings were not performed with purpose.

The Rome Statute of the International Criminal Court provides for war crimes prosecutions for ‘intentionally directing’ or ‘intentionally launching’ attacks that contravene international humanitarian law (in effect, criminalizing the rules of IHL). Jens discusses this in relation to attacks on civilians, but the Statute also proscribes ‘intentionally directing attacks against buildings, material, medical units and personnel’ or against ‘personnel, installations, material, units or vehicles involved in a humanitarian assistance or peacekeeping mission’.

In every case the emphasis is on intentionality, and yet intentionality – as philosophers have demonstrated time and time again – is not the simple, settled matter some legal scholars assume it to be. Jens’s central point is that common-law cultures identify intentionality with purpose or knowledge whereas civil-law cultures widen its sphere to include a conscious disregard of risk or ‘recklessness’. The full argument is here – including an intricate disection of the (geo)politics involved in drafting the Geneva Conventions and the Additional Protocols – but the sharp conclusion is that (for Jens, at least) the strike on the Trauma Centre would not constitute a war crime under the first count (he accepts that neither the GFC nor the aircraft commander possessed the knowledge or the purpose) but could under the second (their actions, and those of others, were reckless). I should add that he recommends the recognition of a new war crime to explicitly address the second count and thereby signal ‘the moral difference between intentionally killing civilians and recklessly killing them.’

The investigation report provides endless, explicit examples of a thoroughly compromised ‘risk management process’ by multiple actors at multiple sites, and this dispersal of responsibility in Kunduz (see map above) and Bagram further complicates the legal situation. Peter Margulies – who does not accept that ‘the lack of intent among US personnel is determinative’ – concedes that ‘the cascading systemic errors in the hospital attack impede the attribution of culpable awareness to one or more specific individuals.’ In his view,

CENTCOM would have been better served by acknowledging that intent was not required [for the commitment of a war crime], but that awareness of risk was distributed among many organizational components, without full awareness concentrated in one or more individuals who could be charged criminally.

Adil Ahmad Haquenotes that Additional Protocol I to the Geneva Conventions requires attackers to do ‘everything feasible’ to verify that their target is a military objective and instructs them in cases of doubt to presume that it is civilian – the Law of War Manual doesn’t follow this standard, but the investigation report does – and here there is such clear evidence of recklessness on the part of many of the US forces involved (whose evidence is shot through with technical failures and radical uncertainty) that, in his view, their decision to press on with the attack ‘was unlawful, irrespective of their good faith.’

(4) Medical neutrality at risk

I noted above that hospitals only lose their protected status if they are used ‘to commit, outside their humanitarian duties, acts harmful to [one of the belligerents]’. It’s a telling provision because its intermediate clause can be read as a tacit acknowledgement that those humanitarian duties – treating the sick and wounded – could otherwise be construed as acts harmful to their enemies.

And there is evidence that this is exactly how both the Afghan government and its military viewed MSF’s activities. When Mathieu Aikins visited Kunduz after the air strike he reported:

Some members of the Afghan government and security forces there had little respect for MSF’s neutrality and resented its treatment of wounded Taliban. When I visited Kunduz in November, their anger was still surprisingly raw, despite the recent destruction of the hospital. “They give them medicine; they transport and treat their injured,” [Colonel Abdullah] Gard, the commander of the [Ministry of Interior’s] quick-reaction force, told me. “Their existence is a big problem for us…. The people that work there are traitors, all of them.”

Gard (seen above) and one of his colleagues told May Jeong exactly the same:

Gard spoke of MSF with the personal hatred reserved for the truly perfidious. He accused the group of “patching up fighters and sending them back out,” a line I heard repeatedly. Cmdr. Abdul Wahab, head of the unit that guarded the provincial chief of police compound, told me he could not understand why in battle an insurgent could be killed, but the minute he was injured, he would be taken to a hospital and given protective status. Wouldn’t it be easier, he asked, wouldn’t the war be less protracted or bloody if they were allowed to march in and take men when they were most compromised? He had visited the MSF hospital three times to complain. Each time a foreign doctor explained the hospital’s neutral status and its no-weapons policy, which mystified him.

In short, it seems that some (perhaps many) in the Afghan security forces – particularly after the humiliation of being forced out of Kunduz – believed that the Taliban were legitimate targets wherever they were and that the fight against them was being hamstrung by what one officer described to Jeong as a ‘silly rule’.

This becomes material because, as I showed previously, the intended target for the air strike was a National Directorate of Security compound whose co-ordinates had been passed to Major Michael Hutchinson, the Ground Force Commander, by Afghan Special Security Forces (who, like him, were unfamiliar with the city): they had identified the NDS compound as a Taliban command and control node, and planned to clear it on their return from the airfield following a casualty evacuation. The AC-130 was supposed to provide Close Air Support, but a series of technical difficulties compromised the accuracy of its sensors and several hours after the Afghan Special Security Forces had left in an armoured convoy with their three casualties the aircrew were still unsure of the location of the target and so requested a verbal description of the NDS compound. This was provided by Afghan forces still inside the Provincial Chief of Police compound: their description matched the MSF Trauma Centre much more closely than the NDS compound, and the aircrew fixed on this as their target.

It’s impossible to know whether this was a mistake or misdirection, and the report fails to identify who provided the description. Hutchinson was shown various photographs but explained that ‘it was dark when everything happened’; he couldn’t remember the name of the Afghan liaison officer and – the redactions make his responses difficult to follow at this point – he wasn’t always sure who he was talking to since he had to rely on interpreters (387-8). But the description obviously had to come from someone who knew the city (which would include Gard and Wahab), and both Aikins and Jeong clearly believe that misdirection is not only possible but also extremely likely. ‘That hospital is in the service of the Taliban,’ Gard told Aikins. ‘I swear to God, if they make it a hundred times, we’ll destroy it a hundred times.’ Hence the headline for Aikins’s searching New York Times report (above): ‘Doctors with enemies: did Afghan forces target the MSF hospital?‘ I should note that David Glazierdismisses all this as ‘highly speculative’ and insists that ‘it simply defies logic’. While the claim is speculative it surely doesn’t defy logic, and Aikins and Jeong make at least a plausible if not definitive case). They are clearly not alone in their suspicions: MSF’s very first question in response to the investigation report was this:

‘What was the physical description of the intended target provided by the Afghan forces and how did it match the description of the MSF hospital?’

The studied refusal to recognise medical neutrality – if that is what this was – emerges from a long history of friction between MSF and the government in Kabul, and it threads its way out into a wider history and geography of deliberate attacks against medical facilities elsewhere in Afghanistan, and – among other recent places – in Gaza (by the Israeli military), in Syria (primarily by the Russian and Syrian Arab Air Forces) and in Yemen (primarily by the Saudi-led coalition which is advised by the United Kingdom on targeting). In February 2014 Thanassis Cambanis was already writing that ‘medical care is now a tool of war’, and in a report issued in May 2016 the World Health Organisation counted almost 600 attacks against medical facilities, doctors and nurses in 19 countries since then. These shocking statistics, which are inevitably imperfect, include attacks by non-state actors, among them the Taliban and Islamic State, but I have emphasised the complicity of state actors – including leading members of the UN Security Council – because it is their actions that determine the course of international humanitarian law and because they are ultimately responsible for what MSF’s president Joanne Liusaw in the wake of the attack on its Trauma Centre in Kunduz as ‘not just an attack on our hospital’ but ‘an attack on the Geneva Conventions.’

In a letter to the UN Security Council issued on 22 September 2016, after a direct and deliberate attack on a humanitarian convoy delivering aid to eastern Aleppo, more than 100 humanitarian organisations noted that:

‘Each [head of state] that accepts a lack of accountability for perpetrators and facilitators of war crimes colludes in the ongoing dissolution of international humanitarian law.’

That dissolution can be seen as a defiant reassertion of the absolutism of sovereign power, because ‘medical neutrality’ is not a neutral claim. Adia Benton and Sa’ed Ashtan persuasively argue that:

The health worker’s claim to impartiality may itself be a stance against the state’s insistence that it is the sole arbiter of who can live and who can die. The local health worker’s claim to an international norm … may be understood as a direct challenge to the state’s claim to sovereignty…. Can ‘‘medical neutrality’’ accurately describe a situation where there is no neutral ground upon which to stand? (‘‘‘Even War has Rules’’: On Medical Neutrality and Legitimate Non-violence’ , Cult. Med. Psychiatry 40 (2016) 151-158).

As the spectral presence of Giorgio Agamben in my slide below implies, this has the liveliest implications for how we are to understand the space of exception and the refusal of its victims to be reduced to the passivity of ‘bare life’.

As I will show in the next post in this series, Syria is the most egregious contemporary case. If some members of the Afghan security forces wilfully misled the Americans into targeting the MSF Trauma Centre in Kunduz, then it seems clear that they objected to the protection extended by IHL to wounded Taliban combatants and those who treat them (though many of those killed in the attack were civilians, despite Alan Dershowitz‘s tawdry attempt to suggest that MSF ‘favoured Taliban fighters over civilian patients’: see Kevin Jon Heller’s magisterial response here). But in Syria not only has the provision of medical aid to those in rebel-held areas been explicitly criminalised by the state’s new Counterterrorism Law which came into effect in July 2012 – the space of exception is far from being a ‘legal “black hole” – but the ban extends to those providing medical aid to sick or wounded civilians. And make no mistake: there have been no mistakes. The murder of doctors and nurses and the bombing of hospitals and clinics in Syria has been deliberate and systematic. The exception to the exception contracts to its vanishing point.

Doctors at War is a candid account of a trauma surgical team based, for a tour of duty, at a field hospital in Helmand, Afghanistan [Camp Bastion]. Mark de Rond tells of the highs and lows of surgical life in hard-hitting detail, bringing to life a morally ambiguous world in which good people face impossible choices and in which routines designed to normalize experience have the unintended effect of highlighting war’s absurdity. With stories that are at once comical and tragic, de Rond captures the surreal experience of being a doctor at war. He lifts the cover on a world rarely ever seen, let alone written about, and provides a poignant counterpoint to the archetypical, adrenaline-packed, macho tale of what it is like to go to war.

Here the crude and visceral coexist with the tender and affectionate. The author tells of well-meaning soldiers at hospital reception, there to deliver a pair of legs in the belief that these can be reattached to their comrade, now in mid-surgery; of midsummer Christmas parties and pancake breakfasts and late-night sauna sessions; of interpersonal rivalries and banter; of caring too little or too much; of tenderness and compassion fatigue; of hell and redemption; of heroism and of playing God. While many good firsthand accounts of war by frontline soldiers exist, this is one of the first books ever to bring to life the experience of the surgical teams tasked with mending what war destroys.

In a faraway land where the rains were dry and the trees blue and the air bittersweet, and where ants were like dogs and birdsong was not, there life went for a song. Everyone and everything died young. Safeguarding its sandy southern perimeter was a coalition of The Free sandbagged in a ghetto the size of a small city. Camp Bastion was the hub in an operation designed to secure for others the freedoms they would have wished for themselves had they been less primitive. The lowlands that surrounded the camp belonged to a warrior people who walked these sands ever since Ibrahim bedded his maidservant and sent her and her firstborn to fend for themselves. The ensuing tiff was never laid to rest. These were Ishmael’s brood.

Inside the camp was a field hospital that, while small, was said to be the world’s bloodiest. It was living proof of reason applied to predicament to save daily those left limbless on account of another of menfolk’s bright ideas. This most progressive of all wars featured sophisticated body armor and capable, rapid air evacuation, meaning that casualties presented alive with injuries more severe than ever seen before in the living. Whether all of the most seriously injured wished to be rescued is another matter altogether, and one they no longer had any say in.

Here is the Contents:

Foreword by Chris Hedges

By Way of Introduction

1 Hawkeye

2 Reporting for Duty

3 Camp Bastion

4 A Reason to Live

5 Legs

6 Apocalypse Now and Again

7 Boredom

8 Christmas in Summer

9 A Record-Breaking Month

10 Kandahar

11 War Is Nasty

12 Way to Start Your Day

13 Back Home

Epilogue

‘In Doctors at War, Mark de Rond shines a light on a reality we are not supposed to see. It is a reality, especially in an age of endless techno war, we must confront if we are to recover the human’ — from the Foreword by Chris Hedges. More here.

If we can eliminate enemy threats without placing boots on a battlefield, then why not do so? That’s one of the unspoken questions raised, and largely unanswered, by “National Bird,” Sonia Kennebeck’s elegantly unsettling documentary about the United States’ reliance on aerial combat drones.

The weapons themselves, though, demand less of her attention than their psychological impact on three former operators and current whistle-blowers. Identified only by first names (though one full name is visible in a shot of a 2013 exposé in The Guardian), all three were involved in some form of top-secret data analysis and the tracking of targets. Justifiably nervous, they wear haunted, closed expressions as they relate stories of guilt, PTSD and persecution…’

The documentary includes a re-enactment (see still above) of what has become a signature drone strike to critics of remote warfare – the attack on a ‘convoy’ of three vehicles in Uruzgan in 2010 that I analysed in Angry Eyes (here and here); the strike was orchestrated by the crew of a Predator but carried out by two attack helicopters. Kennebeck based her reconstruction on the report from the same US military investigation I used, though I think her reading of it is limited by its focus on the Predator crew in Nevada and its neglect of what was happening (or more accurately not happening) at operations centres on the ground in Afghanistan. She’s not alone in that – follow the link to the second part of Angry Eyes above to see why – but what she adds is a series of vital interviews with the survivors:

I found the survivors of the airstrike and was the first person to interview them and get their first-person accounts… Their stories give a much larger dimension to the incident and reveal that parts of the military investigation had been sugarcoated.

Winston Cook-Wilsonagrees that the cross-cutting between the strike and its victims is immensely affecting:

The most powerful section of Kennebeck’s film, by far, are the interviews with family members and witnesses of a mistaken drone attack which killed 22 men, women and children in Afghanistan. Before meeting the Afghani mother who lost her children, the man who lost his leg in the explosion, and others, Kennebeck shows the attack in re-enactment that utilizes frighteningly blurry drone vision. Slightly overdone, static-ridden voiceovers from a radio transcript are included. The emotional footage in Afghanistan here is undeniably powerful; Kennebeck then unexpectedly cuts in grainy footage, filmed by one of the families of the victims, poring over their maimed remains.

This section of the film induces nausea, grief, and confusion all at the same time.

‘Frighteningly blurry drone vision’ is exactly right, as I’ve argued elsewhere (you can find a discussion of this in the second of my ‘Reach from the Skies’ lectures and in the penultimate section of ‘Dirty Dancing’, DOWNLOADS tab). Here is Naomi Pitcairn who sharpens the same point:

We can see, clearly, how little they can actually see: tiny dots, like ants walking slowly, in single file. This is the all seeing but lacking feeling, understanding and cultural context, vision of a drone video feed and the drone operators callousness in the transcript seems to reflect that. Their bloodlust combined with the minimalism of the feed is intense in its very … primitivism.

Jeanette Catsoulis also thinks the cross-cutting between the strike and the survivors is highly effective (see also Susan Carruthers, ‘Detached Retina: The new cinema of drone warfare’, in Cineaste, who regards those sequences as providing ‘a more profound, affecting, and sustained reckoning with what drones do than anything else to date’), but she doesn’t think it sufficient:

If “National Bird” wants to persuade us that the emotional and collateral damage of this technology is greater than that caused by conventional weapons, it needs to widen its lens. Interviews with military specialists able to elucidate the complex calculus of risk and reward would have been invaluable in balancing the narrative and perhaps clarifying the ethical fuzziness.

Even so, there’s a sense that some unwritten human compact has been broken. As an ominously beautiful drone’s-eye camera glides above peaceful American streets, we’re uncomfortably reminded that an invisible death could one day hover over us all.

So it could – perhaps especially now. As a reminder of that dread possibility, one of the phrases that recurs in the transcript from the Uruzgan strike is ‘military-aged males’ (with all that implies), so here is an image from Tomas van Houtryve‘s photographic series Blue Sky Days. It’s also called ‘Military-Aged Males‘:

It shows civilian cadets assembling in formation at the Citadel Military College in Charleston, South Carolina.

On this terrible morning, with Donald Trump elected as President-designate of the United States, what to say? Wrestling with sleeplessness last night, I started to think about the Statue of Liberty (bear with me). I wrote about its multiple valences more than twenty years ago in Geographical Imaginations:

Frédéric-Auguste Bartholdi‘s original proposal was for a lighthouse in the likeness of a woman to be raised at the Mediterranean entrance to the Suez Canal as a symbol of the nineteenth-century expansion of Europe. Its title, Egypt carrying light to Asia, was intended to assert the historical mission of Europe – with a colonized Egypt acting as its handmaiden – to bring “enlightenment” to the Orient. Bartholdi spent two years making plans and models but in 1869 – the year the Canal opened – the Khedive Ismail withdrew his support and it was not until 1871 that Bartholdi was able to reactivate his scheme.

By then, in the wake of the Pais Commune, the project had been transformed and relocated. One of his patrons, Édouard de Laboulaye, suggested that a monument be raised on the shores of the New World to symbolize Liberty Enlightening the World. The representation of Liberty as a woman derived from classical antiquity, but this ‘whole allegorical apparatus’, as Maurice Agulhon called it, had been codified in France in the late seventeenth century. When the Revolution occurred, Liberty already had an established iconographical status and a decree of 1792 adopted her as the seal of the republic: ‘the image of France in the guise of a woman, dressed in the style of Antiquity, standing upright, her right hand holding a pike surrounded by a Phyrgian cap or cap of liberty.’

By the opening decades of the nineteenth century the use of ‘Marianne’ as a symbol of both Liberty and the Republic had become a commonplace. This was true in the most literal of senses. “Where was this woman to be seen?” ask Agulhon. The answer: “all over the place”. Paris had two statues of her, in the Place de la Concorde and the Place Vendôme, and many other towns had their own effigies. In 1848 she appeared on the second seal of the Republic, wearing a diadem of corn with seven rays of the sun encircling her head in a spiked halo.

The resemblance to the head of the American statue is striking, but a sunburst was also the Bartholdi family emblem and, still more significantly, it was intimately associated with the reign of Louis XIV, the ‘Sun King’. To adorn Liberty with a sunburst was thus in a sense ‘to “crown” her’, Kaja Silverman argues, ‘and thereby align her with a tradition of stable and conservative government.’

That Liberty should be represented by a woman was clearly not without irony. In practice, Joan Landes remarks,

the assault on paternalism was limited by force … and by the redirection of women’ public and sentimental existence into a new allegory of republican, virtuous family life. Liberty herself is a profoundly ironic symbol, a public representation of a polity that sanctioned a limited domestic role for women … If Liberty represented woman, surely it was as an abstract emblem of male power and authority.

The power of patriarchy was reasserted still more forcibly after the fall of the Commune with the triumph of the bourgeois republic and its cult of respectability. As Roger Magraw observed, ‘the official Mariannes who adorned town halls by the 1880s wore a halo of flowers and the motto Concorde, moving towards that anodyne statue which France sent to her fellow capitalist republic as the State of Liberty.’ Anodyne indeed: Silverman argues that Bartholdi virtually erased the corporeality of the body. Thus he ‘completely buries the female form beneath hear classic drapery’ and ‘any thought that a body might nevertheless lurk beneath those folds is abruptly put to flight by the possibility of entering the statue and climbing up inside it.’ She is well aware of the sexual connotations of such a reading, of course, and moves quickly to foreclose them. ‘Liberty is precisely an extension of the desire to “return” to the inside of the fantastic mother’s body,’ she proposes, ‘without having to confront her sexuality in any way.’ Viewed in this light, therefore, Liberty is rendered non-threatening and even ‘safe’.

It was thus from within a many-layered iconographical tradition that Laboulaye’s proposal was made. He was Professor of Comparative Law at the Collège de France and although he never crossed the Atlantic he was regarded as France’s greatest expert on the United States. Like many other republicans at the time, he regarded the United States as a model of the ideal society and he and his companions were convinced that a Statue of Liberty, given by France to America, would symbolize their most cherished principles. For this reason Bartholdi was urged to ensure that the statue should ‘not be liberty in a red cap, striding across corpses with her pike at the port’ – a reference to Delacroix’s famous Liberty guiding the people to the barricades (below) – but ‘the American liberty whose torch is held high not to inflame but to enlighten.’ Bartholdi agreed. ‘Revolutionary Liberty cannot evoke American Liberty,’ he declared, ‘which after a hundred years of uninterrupted existence, should not appear as an intrepid young girl but as a woman of mature years, calm, advancing with the light but sure step of progress.’

For all there enthusiasm of the projects initiators, however, public subscriptions were slow – even Gounod conducting La liberté éclairant le monde at the Paris Opéra brought in a mere 8,000 francs – and in American they were slower still. Bartholdi made a show of offering the statue to Philadelphia and Boston; other American cities submitted bids until at last prominent subscribers in New York were goaded into action.

In 1875 Bartholdi started work in his Paris atelier:

He soon realized the magnitude of the task and invited Gustave Eiffel to design the wrought-iron bracing needed to support the copper sheets that would form the outer skin of the sculpture. It took several years to complete the disembodied sections of the statue, but by the spring of 1883 Bartholdi was at last ready to assemble them. By the end of the year, as Victor Dargaud‘s canvas shows, the statue still surrounded by its scaffolding was looming about the rue de Chazelles.

That same year Emma Lazarus published ‘The New Colossus’ to raise money for the statue’s plinth; its famous lines were eventually mounted inside the lower level:

The government of France presented the Statue of Liberty to the United States on the Fourth of July 1884, and five months later it was dismantled, shipped across the Atlantic and reassembled on Bedloe’s Island in New York harbour.

Astonishingly when the inauguration ceremony was held in October 1886, all women were barred except for the wives of the French delegation (led by Bartholdi). American suffragists held their own simultaneous ceremony, and issued this pointed declaration: ‘In erecting a Statue of Liberty embodied as a woman in a land where no woman has political liberty, men have shown a delightful inconsistency which excites the wonder and admiration of the opposite sex.’

This is only a partial narrative but its echoes this morning are only too sonorous – not least the casual Orientalism, the overpowering whiteness, the complicated sexism and (in blessed counterpoint) Lazarus’s defiant acceptance of the exile and the refugee.

And so, for all the baggage carried by Liberty, if I could draw her now I would show an endless line of refugees; at the very back, a woman in a long flowing dress, her crown askew, using her battered torch as a crutch as she limps along in the dust, hoping against hope to be allowed to cross the border; and on an island in New York Harbor a new, glittering faux-gold statue of a man raising his searchlight in his tiny hands, and on the base Dante‘s immortal instruction: ‘Abandon hope, all ye who enter here….’

Yet today of all days we surely cannot afford to abandon hope. Never has it been more urgent for scholars to reach out far beyond the academy, to create and engage new publics, and to help revitalize a critical and participatory political and intellectual culture – one in which knowledge trumps ignorance, compassion hostility and solidarity selfishness.

The Transnational Institute has published a glossy version of a chapter from Steve Graham‘s Vertical – called Drone: Robot Imperium, you can download it here (open access). Not sure about either of the terms in the subtitle, but it’s a good read and richly illustrated.

Steve includes a discussion of the use of drones to patrol the US-Mexico border, and Josh Begley has published a suggestive account of the role of drones but also other ‘seeing machines’ in visualizing the border.

One way the border is performed — particularly the southern border of the United States — can be understood through the lens of data collection. In the border region, along the Rio Grande and westward through the desert Southwest, Customs and Border Protection (CBP) deploys radar blimps, drones, fixed-wing aircraft, helicopters, seismic sensors, ground radar, face recognition software, license-plate readers, and high-definition infrared video cameras. Increasingly, they all feed data back into something called “The Big Pipe.”

Josh downloaded 20,000 satellite images of the border, stitched them together, and then worked with Laura Poitras and her team at Field of Vision to produce a short film – Best of Luck with the Wall – that traverses the entire length of the border (1, 954 miles) in six minutes:

The southern border is a space that has been almost entirely reduced to metaphor. It is not even a geography. Part of my intention with this film is to insist on that geography.

By focusing on the physical landscape, I hope viewers might gain a sense of the enormity of it all, and perhaps imagine what it would mean to be a political subject of that terrain.

If you too wonder about that last sentence and its latent bio-physicality – and there is of course a rich stream of work on the bodies that seek to cross that border – then you might visit another of Josh’s projects, Fatal Migrations, 2011-2016(see above and below).

There’s an interview with Josh that, among other things, links these projects with his previous work.

I have a couple of projects that are smartphone centered. One of them is about mapping the geography of places around the world where the CIA carries out drone strikes—mostly in Pakistan, Yemen, and Somalia. Another was about looking at the geography of incarceration in the United States—there are more than 5,000 prisons—and trying to map all of them and see them through satellites. I currently have an app that is looking at the geography of police violence in the United States. Most of these apps are about creating a relationship between data and the body, where you can receive a notification every time something unsettling happens. What does that mean for the rest of your day? How do you live with that data—data about people? In some cases the work grows out of these questions, but in other cases the work really is about landscape….

There’s just so much you can never know from looking at satellite imagery. By definition it flattens and distorts things. A lot of folks who fly drones, for instance, think they know a space just from looking at it from above. I firmly reject that idea. The bird’s eye view is never what it means to be on the ground somewhere, or what it means to have meaningful relationships with people on the ground. I feel like I can understand the landscape from 30,000 feet, but it is not the same as spending time in a space.

Anjali Nath has also provided a new commentary on one of Josh’s earlier projects, Metadata, that he cites in that interview – ‘Touched from below: on drones, screens and navigation’, Visual Anthropology 29 (3) (2016) 315-30.

It’s part of a special issue on ‘Visual Revolutions in the Middle East’, and as I explore the visual interventions I’ve included in this post I find myself once again thinking of a vital remark by Edward Said:

That’s part of the message behind the #NotaBugSplat image on the cover of Steve’s essay: but what might Said’s remark mean more generally today, faced with the proliferation of these seeing machines?

As I continue my work on the targeting of hospitals and ambulances, doctors and nurses, and on the precarious provision of medical care in Syria, I’ve been watching Skye Fitzgerald‘s remarkable documentary 50 Feet from Syria, whichis now available on iTunes and (in some places) on Netflix:

With a suitcase full of donated stainless-steel bone implants, Syrian-American surgeon Hisham Bismar arrives at a Turkish hospital on the Syrian border, ready for anything. What he finds is horror, chaos, and an ocean of refugees in need of medical care: colleagues who perform operations without anesthesia, stories of Syrian government snipers targeting pregnant women and children, and images of 55 gallon barrels filled with shrapnel and TNT deliberately dropped on civilians.

With dull drill bits and ill-fitting bone and joint implants Bismar repairs the bodies of the wounded fortunate enough to find their way to the hospital – both civilians and fighters. Amongst this remarkable work, remarkable people abound: “M”, a ‘Turkish Schindler’ selflessly crossing the border each day to retrieve the wounded and ferry them to the care of surgeons, and “AM” a hero among his peers for his willingness to live for years in Syrian field hospitals repeatedly bombed by the Assad regime.

50 Feet From Syria is a portrait of a quiet and determined man, performing intricate acts of medical necessity undeterred by the chaos and complexity of war around him. The film serves as a snapshot in time for the current plight of Syrian refugees. It also indelibly communicates the human cost of one of the most brutal, dehumanizing conflicts in modern history that continues to destroy and displace millions of lives.

Someone who has demonstrated the variability of distance in these situations is the remarkable British surgeon David Nott, who has both worked in field hospitals inside Syria and also advised colleagues in Aleppo and elsewhere from London by Skype and whatsapp (the most intimate of remote medicines):

You can read much more on his work – and on the medical underground in Syria more generally – in Ben Taub‘s compelling account of ‘The shadow doctors’ at the New Yorkerhere.

I’ve drawn on these and many other accounts for my ‘Surgical strikes and modern war’: much more to come very soon.